Synopsis The vessel, with three passengers and an operator on board, departed Tofino, British Columbia, on a three-hour trip to watch marine life. All wore coverall PFD (personal flotation device) suits; while the passengers' suits were properly worn, the operator's suit was partially zipped. After watching whales, the operator decided to show the passengers marine life in the vicinity of Plover Reefs. While in that area, the boat was swamped and broached by a large swell, which threw all the occupants into the turbulent water. The rapidity of the occurrence precluded transmission of a Mayday message. When the boat did not arrive at its destination, the owner initiated Search and Rescue action. Two passengers were rescued after about two hours. The operator and one passenger lost their lives. The Board determined that the OCEAN THUNDER was swamped and rolled suddenly to a large angle, throwing all occupants into the cold water. A factor contributing to the occurrence was that the operator did not fully appreciate the conditions the boat would meet at the time of the accident in the turbulent waters in the vicinity of reefs. Contributing to the loss of lives were: anxiety associated with sudden immersion in cold water, the lack of effective communication equipment, and the absence of emergency (medium range) communication equipment, which resulted in a delay in initiating a Search and Rescue response. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The boat is an extended version of a Titan class 5.5 m, designed by a naval architect in Vancouver, B.C. The deep V aluminium hull with longitudinal stiffeners, watertight compartments and modular fuel tank is designed to withstand rough conditions associated with whale watching on the west coast of Vancouver Island, which is exposed to the Pacific Ocean swell. The deck is self-draining, with cable routing and a battery compartment under deck. Two inflatable sponsons (chambers), one on either side, provide buoyancy and stability to the boat. Attached to the chambers on the inboard side of the boat are grab lines, which provide additional grip for the passengers. These grab lines do not extend to the waterline on the outside of the inflatable chambers. On deck, four benches with tubular framing seat backs provide seating for 12 passengers. The seat backs also provide hand holds for persons seated behind. There is no additional restraining device. Astern of the last bench is a small wheel-house booth, which houses navigation equipment, steering and propulsion controls. The operator stands in the booth, steering and navigating. Mounted at the transom were two new Mercury outboard engines, with only about 60 hours of recorded running time on them. Two throttles mounted in the wheel-house provided remote control for the engines. Each engine was fitted with an emergency cut-off switch. 1.1.2 Stability of the Boat The boat had never undergone a formal stability test, nor was one required. However, extensive sea trials were conducted in the presence of the owner's naval architect in Vancouver, to verify the boat's performance and seaworthiness. Rigid hull inflatable (RHI) boats are widely used as rescue boats because of their good range of stability and their seaworthiness in bad weather conditions. The OCEAN THUNDER had a high degree of residual stability such that it would return to the upright even from large angles of heel. This is depicted in a video showing the boat undergoing sea trials while skimming over wave crests at high speed and undergoing a forced roll. 1.2 History of the Voyage On Sunday, March 22, three passengers were booked for the 1200 Pacific standard time (PST)[3] departure to go on a whale-watching trip from a prominent whaling station in Tofino. The trip was scheduled to last about three hours. The boat arrived from the 0900 trip and began disembarking passengers. The investigation revealed that the boarding passengers were made aware that, on the previous trip, the boat had been partially swamped while transiting a channel and that some passengers had been frightened by the experience. The boat operator assured the waiting passengers that it was safe to make the trip and instructed them on how to don the coverall personal flotation device (PFD) suits (locally referred to as floater suits). No other safety information was provided. All three passengers donned coverall PFD suits. The passengers tightened the ties around the ankles and wrists and wore rain gear over the suit. The passengers observed that the operator had only donned his suit loosely and did not zip it up fully, leaving part of his chest and head exposed. The boat then departed from the wharf at 1215. The operator steered the boat through the myriad channels forming Clayoquot Sound to the open Pacific Ocean where he slowed down upon encountering heavy, confused swells in the vicinity of reefs known as the La Croix Group, Foam Reefs and Plover Reefs. The passengers then spent about half an hour looking at whales before the operator decided to show them some marine life in the vicinity of Plover Reefs. The area consists of numerous reefs with white water around them. The waters were turbulent and the sea and swell were confused. As the boat made its way through the turbulent waters near the reefs and the operator negotiated a channel between rocks, a wave from the stern swamped the boat. Immediately thereafter, the boat was broached (broadsided) and another large swell wave struck the boat from the port side. This raised the port side to a near vertical angle and then the wave broke over the boat. The suddenness of the roll to a large angle and the breaking wave caused the passengers and the operator to be thrown over the starboard side and into the sea. No Mayday message was transmitted. There is conflicting information as to whether the boat capsized. One account was that the boat had rolled suddenly to a large angle throwing all occupants overboard. The operator and two passengers, one male and one female, found themselves together in the turbulent waters. They could not see the boat, which had drifted away from them. The male passenger, who was a non-swimmer, panicked and was soon lost. His body was recovered later. The operator cast off his boots and floated with the surviving passenger, providing encouragement, and advised her not to go close to the rocks. After more than an hour, the operator was observed to be getting cold and lapsing into bouts of unconsciousness. The surviving passenger (from this group of three) then saw the boat, which was upright and had drifted within sight. She swam towards the boat and hung onto it. By now, she was weak and her attempts to board the boat were unsuccessful. When she saw a rescue plane overhead, she found the strength to board the boat and was rescued by a vessel that had been directed to the area by the search plane. The operator's body was recovered from the water nearby. Meanwhile, the third passenger, who was also thrown off the boat, found herself carried some distance away from the group of three and alone in a lagoon of calmer water. She could not see the others or the boat. She floated, without exerting herself, with her face up; after an hour, she drifted off into unconsciousness. She was rescued sometime later. 1.3 Injuries to Persons The two female survivors and the operator were swimmers, while the male passenger was a non-swimmer. The male passenger and the operator lost their lives due to drowning. When rescued, the survivor who had made her way back to the boat was suffering from mild hypothermia. She was treated at a local hospital and later released. When the rescuers found the other female passenger, who was unconscious, she was suffering from severe hypothermia--there was no pulse and her body temperature was low. Artificial respiration was begun and she was revived. She was rushed to the hospital in Tofino where she was admitted and treated; she was released a few days later. 1.4 Damage 1.4.1 Damage to the Boat Upon recovery, an examination of the boat revealed, amongst others, the following: The throttles of both engines were found set at the half-ahead position. The port engine had a smashed lower cowling and a cracked upper cowling, its air filter was found soaked with water, and water was found on top of the air intake throttle plates. The number four cylinder was full of water and, in the other cylinders, there was indication of water on the spark plugs. The starboard engine was tilted up past its limit. There was damage to the cowling and the starter solenoid battery connection had deposits of green verdigris corrosion. Water was found throughout the cowling. All cylinders showed signs of water ingestion and cranking the engine expelled water from the spark plug holes. The tachometers, port hour meter, very high frequency (VHF) radio, Global Positioning System (GPS) and radar were found to be damaged by sea water; however, all other instruments and wiring on the main instrument panel were functional. The ignition safety cut-off lanyard was missing. The battery connections were green and corroded. The operator's cabin window pane was broken, and scratches and scuffs were found on the port side of the hull. On top of the operator's cabin, the radar dome, the antenna and lights were intact. 1.4.2 Damage to the Environment There was no pollution as a result of the accident. 1.5 Certification 1.5.1 Vessel Certification 1.5.1.1 Transport Canada Regulatory Requirements and New Initiatives Currently, a vessel under five gross tons and carrying 12 or fewer passengers is not required by the regulations made pursuant to the Canada Shipping Act to be inspected by Transport Canada Marine Safety (TCMS). At the time of the occurrence, Transport Canada (TC), in conjunction with industry stakeholders, was reviewing the Construction Standards for Small Vessels (TP 1332E). For the purposes of inspection of small vessels, be they fishing vessels or passenger vessels, it is the intention of TC to raise the tonnage limit of uninspected passenger vessels to 15 gross tons.[4] The proposed standards are divided into two segments for application: one for commercial vessels and the other for pleasure craft. The standards are nearing the final stages; however, there is resistance from the stakeholders to incorporate minimum stability criteria for small vessel commercial operations. Following the development of the construction standards, additional initiatives addressing crew certification, safety equipment carriage requirements, and voyage limitations will be developed. Currently, no construction standard exists for RHIs used for carrying passengers and engaged in operations similar to whale watching, which tend to be operated by a single person and make trips in exposed areas of open waters. However, a TC standard entitled Standards for Rescue Boats (TP 7322E) does exist for RHIs used as rescue boats.[5] These rescue boats, also referred to as fast rescue craft, are designed for use in rough weather conditions similar to those found on the west coast of Vancouver Island. The standards require, in part, that: the boat meet stability criteria; becketed lifelines be fitted inside and outside the boat, giving person(s) in the water a hand-hold so they may stay with the boat; and the boat be equipped with a boarding ladder to help persons boarding from the water. 1.5.1.2 Industry Initiatives At the time of the occurrence, the British Columbia Whale Watching Society of Victoria Harbour, an industry association, had been reviewing the operational practices for whale-watching boats with a view to establishing standards. The proposed (local) industry standards, entitled Standards for Victoria Area Whale Watching Companies Operating Vessels of Less Than 5 Gross Tons and Carrying 12 or Fewer Passengers, deal with vessel construction, safety equipment, communication equipment, navigation equipment and operator proficiency. These standards call for equipment in excess of that currently required under TC regulations, and include the following: that open boats should carry a full-length Minister of Transport (MOT/CCG)- approved flotation suit for each adult and a correctly sized, approved lifejacket forc each child. Suits and lifejackets must be worn by passengers and crew;[6] that three additional flares be on board to fit the pocket of operator's floater suit; that open vessels operated by a single operator be fitted with an engine kill switch and lanyard/emergency engine shut-off; that the vessel be fitted with a waterproof VHF Channel 16 emergency transmitter with long-life battery secured to a float and tethered to the boat, or an emergency position indicating radio beacon (EPIRB) of a type suitable to the boat's activity and operating range (manually activated); that an emergency calling decal with Mayday instructions be on board for the benefit of persons other than the operator; and that the vessel be fitted with a GPS for navigation. 1.5.2 Personnel Certification Currently, there is no regulatory requirement under the Canada Shipping Act for boats the size and type of the OCEAN THUNDER--under five gross tons and carrying 12 or fewer passengers--to have their operators certificated. However, joint new initiatives currently under consideration by the industry and TC will address the marine qualification and certification requirements. In this instance, the operator of the OCEAN THUNDER had a valid Certificate of Competency as Master of Small Passenger Craft and a certificate to operate temporarily as an Engineer on two of the larger vessels operated by the same company. He had also successfully completed courses in Simulated Electronic Navigation I (which gives training in electronic navigation aids and radar), A1 Marine Emergency Duties (MED), Standard First Aid, Radiotelephone Operator's Restricted Certificate (Maritime), Open Water Dive certification and Flat Water Canoeing. Of the three passengers, the two who survived had spent some time with recreational water craft, but none had any formal training. 1.6 Personnel History The operator of the vessel had been employed by the company for just over a year. His experience included two year's service as a deckhand on larger vessels at a different location in British Columbia and varied experience in the outdoor recreation industry. He underwent the employer-sponsored training program, which comprised a training course conducted by a local company and hands-on training and familiarization of the area by working with other operators. Following an evaluation of his performance, he was employed as an operator of the OCEAN THUNDER. The operator had made many trips in the vicinity of Plover Reefs. His daily schedule varied depending on the number of trips that were required to be made. Generally, in the peak tourist season, the day started with the morning trip at 0900 and ended before sunset after the third trip. 1.7 Weather and Current Information 1.7.1 Weather Forecast The three-day weather forecast for the west coast of Vancouver Island issued by Environment Canada at 0624, Saturday, March 21, included a gale warning. The forecast predicted a fairly intense system crossing the coast on Saturday, bringing rain and wind. This would give way to cool unstable air and showers on Sunday, March 22, followed by another frontal system which would bring more rain and wind on Monday, March 23. The 1030 forecast on Sunday, March 22, called for light winds rising to easterly, 15 to 20 knots (kn) overnight and 20 to 30 kn on Monday morning. The skies were predicted to be mainly cloudy, with a few showers and 3 m to 4 m seas. The outlook was for strong to gale force winds. At the time of the occurrence, the weather at the La Perouse weather buoy, south-west of Tofino, recorded wind speeds of 10 kn, significant wave height of about 3 m to 4 m, and air and surface temperatures of 11.5C. Reportedly, information from other vessels in the area indicated that the morning weather had moderated in the afternoon. On the evening of March 23, while the investigation into this occurrence was in progress, a frontal system passed over Tofino cutting off power supply to most of the city. The severity of the system confirmed the accuracy of the gale warning in the weather report. 1.7.2 Current Information The Sailing Directions--British Columbia Coast (South Portion) Volume 1 warns that the tidal streams are accentuated by the in-draught into the large sounds, especially during strong winds from south-east and south-west. Low water at Tofino, on March 22, was at 1355. 1.7.3 Cold Water Survival The sea water temperature was 11.5C. Studies of cooling rates for an average adult holding still in ocean water of 11.5C (wearing a standard lifejacket and light clothing) show a predicted survival time of about 1.8 hours. Extra body fat can increase survival time. The operator was 1.79 m tall and weighed approximately 97 kg. He was wearing a coverall PFD suit, which was not fully zipped, over seasonal clothing. The passenger who lost his life was 1.86 tall and weighed about 147 kg. He was a non-swimmer and was wearing a coverall PFD suit which was fully zipped over seasonal clothing. The donning of the suits protected those on board from the harsh environmental conditions. According to the manufacturer of the suit, the thermal protection afforded by the suit had the potential to increase their survival time between two to four times. 1.8 Search and Rescue Issues 1.8.1 Sail Plan Monitoring The vessel's sail plan was left with the company dispatcher but there was no established regular calling-in procedure to keep track of the boat's progress. Rather, the boat was in contact with the dispatcher and other boats as required. Communication was by way of a VHF radiotelephone (R/T). The dispatcher had observed, and the operator was aware, that the radio reception from the OCEAN THUNDER on the day of the occurrence was such that they were frequently out of touch when the boat was in the open waters. There was no known problem associated with VHF coverage or general radio reception in the area. The general practice of the operator was to notify the dispatcher when the boat was on her return trip. 1.8.2 Search and Rescue Operations When the boat did not call in or return at the scheduled time, the dispatcher contacted other vessels in the area at about 1450 and the owner some 15 minutes later. When it was established that no other vessels had sighted the OCEAN THUNDER at that time, the owner called Tofino Air and an aircraft was tasked to search for the OCEAN THUNDER. The owner also requested other vessels in the area to assist in the search, and contacted the Tofino Lifeboat to apprise the Lifeboat of the overdue vessel. At 1541, the Tofino Lifeboat apprised the Rescue Coordination Centre in Victoria of the situation, setting in motion an official Search and Rescue (SAR) response. The search was conducted by two aircraft and nine surface craft. The Tofino Air fixed-wing aircraft was on scene at 1557 and saw the boat drifting in the vicinity of Plover Reefs with a person sitting in it. Other boats belonging to commercial operators and to the Canadian Coast Guard (CCG), which had joined the search, rescued the passengers and retrieved bodies of the other persons who had been on board the OCEAN THUNDER. 1.9 Life-saving Equipment The OCEAN THUNDER carried life-saving equipment for a vessel of its size and type.[7] In lieu of the lifejackets, a one-piece coverall PFD suit was carried for each person on board, and each passenger and the operator wore one. Some of the suits were constructed to CAN/CGSB-65.11-M88 (Personal Flotation Devices) standards, and carried a marking of Anti-Exposure Suits.[8] While the passengers had fully zipped their suits, the operator had not. The six flares required by the Small Vessel Regulations, and a medical kit, were stowed in the bow locker. None of the survivors knew where this emergency equipment was located, nor were they instructed in its use. The flares became inaccessible when the occupants of the boat were thrown into the water. 1.10 Emergency Signalling Equipment Emergency signalling equipment (ESE) can be categorized as self-activated and survivor-activated, as outlined in the following table.[9] Short range ESE is primarily targeted at other craft that are within visible range, to initiate rapid rescue response. In long range ESE, radio equipment is used. The longer radio range permits transmissions to be targeted at a wide range of shipboard and shore-based radio stations for a rapid SAR response. The OCEAN THUNDER carried neither an emergency (portable) VHF radio nor an EPIRB, nor is there a regulatory requirement for the carriage of such equipment. The rapidity with which the occupants of the boat were thrown into the water precluded the transmission of a Mayday message. There are various EPIRBs available on the market; their differences in position accuracy can affect SAR response time and, hence, the eventual success of a SAR mission. Care should be exercised in determining which equipment is best suited for operations. The CCG has undertaken an initiative to upgrade the VHF radio distress system by providing VHF Digital Selective Calling (DSC) services. This new digital radio transmits (either by hand-held or fixed radio) an automatic, digital, all stations distress alert signal on VHF Channel 0. This distress alert includes vessel identification, position (as obtained from GPS) and nature of distress. Commercial vessels larger than 8 m will be required to carry this VHF DSC radio, but smaller vessels may do so voluntarily. 1.11 Safety and Record Keeping Safety meetings were held by the company on a periodic basis, with the last meeting having taken place some two weeks before the occurrence. The investigation revealed that the coverall PFD suits were maintained and that they were periodically inspected by the owner's representative. There is no regulatory requirement to keep a maintenance record for PFD suits; however, the owner kept a record.